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UST SYSTEM RETROFIT OR REPAIR <br /> (Submit minimum of 2 sets of plans& applications as originals will be retained by EHD) <br /> 1. Site map enclosed YES [] NOX] <br /> 2. Manufacturer's spec sheets attached for all equipment to be installed YES 4 NO [] <br /> 3. Description of work to be completed (If adding piping, UDC's, or other UST equipment, or performing tank tnn upgrade, <br /> us the UST Installation Application pa es 4-8 s necessary for a timely planev w): L C <br /> 4. De�sc.��oOn of eOquipment to����Attach drawings/blueprints as necessary): <br /> 5. All equipment is State certified or approved. YES k NO [] <br /> 6. Decontamination Procedures: <br /> a. Will piping be decontaminated prior to removal? YES [ ] NO [] <br /> b. Identify contractor performing decontamination: <br /> Name Phone( ) <br /> Address City Zip <br /> c. Describe method to be used for decontamination: <br /> d. Describe how rinsate material will be stored onsite prior to manifesting offsite: <br /> e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br /> Hauler Name Phone( ) Hauler Reg# <br /> Address City Zip <br /> Permitted Disposal Site <br /> 7. a. Describe the method that will be utilized to purge and/or inert the piping: <br /> b. Piping Hauler: <br /> Name Phone ( ) <br /> Address City Zip <br /> Hauler Registration # (if hauled as hazardous) <br /> c. Piping Disposal Site: <br /> Name Phone ( ) <br /> Address City Zip <br /> EPA ID# (if transported to a permitted TSD facility) <br /> 8. Is the sampling firm an independent third party from the contractor? YES [ ] NO [] <br /> 9. Describe, in detail, how the soil and/or water sample(s) beneath the piping or dispenser will be obtained: <br /> 10. Handling of excavated soil (Contaminated Soil Hazardous Waste Hauler): <br /> Name Hauler Registration # Phone ( ) <br /> Address City Zip <br /> b) If soil is not to be hauled, describe what will be done with it: <br /> 2 <br />